Minor Surgery Flashcards
_______ fluids of ALL patients should be considered infectious.
blood and body fluids
_______ is the most commonly transmitted infection.
Hepatitis B
Anesthetics are dividided into 2 groups:
esters and amides
2% Glutaraldehyde has a (low/high) tissue toxicity.
Low
Name 2 required universal precautions (OSHA):
Use barriers (gloves, ppe) Sharps management
Use sterilization for _____, disinfecting for ______.
S - tools
D - living tissue
2% Glutaraldehyde takes how long to work?
10 mins to disinfect
10 hours to sterilize
Boiling can effectively sterilize at:
> 30 mins
Dry heat can effectively sterilize at:
160C / 320F x1 hour
Autoclave rules:
15 psi at 121c for 15 mins
Intact skin can be disinfected with:
10% betadine x3
0.4% chlorhexidine gluconate
Why do we irrigate with normal saline instead of H2O2?
H2O2:
slows wound healing
promotes tissue necrosis
If skin is punctured, and large items are still in the skin, you should:
Secure and refer
Let puncture wounds heal by ___ intention.
third - in case something is still inside
Dont suture wounds older than:
8-12 hours
24 hours on the face
If you can’t rule out these kinds of damage, you should always refer:
nerve
tendon
vasculature
bone
Normal scar healing is called ______, while extending beyond the original area is called ________.
hypertrophic
keloid
Healing stages:
1 - hemostasis
2 - inflammation
3 - proliferation (granulation)
4 - remodeling
Healing stages - Hemostasis is also called _______, and is characterized by formation of a ___________.
coagulation
fibrin clot
Healing stages - Inflammation begins _____, days 1-4. Cytokines are secreted by ________, complement cascade is triggered, and _______ arrive in 5-6 hours, staying 3-4 days to destroy bacteria.
immediately
platelets
neutrophils
Healing stages - inflammation:
__________ transition from inflammation to repair and phagocytize.
macrophages
Healing stages - inflammation:
re-epithelialization
basal cells
New karatinocytes proliferate ___ days after injury.
1-2
Neovascularization is:
angiogenesis, brings oxygen and nutrients
Remodeling strength at 3-4 weeks:
30-40%
Remodeling strength at 1 year:
80%
Bromelain can help increase _______ formation.
collagen
Healing intention - primary:
suture a clean wound
bandage and let heal
Healing intention - secondary: full thickness, into subQ
left open, healed by granulation
used with significant tissue loss or contamination
Healing intention - tertiary:
without significant tissue loss -> clean, pack, cover, leave open 3-5 days, then suture if non-infected
* dog bite
* puncture with contaminated tool
> you may want to reopen if the skin starts healing over too soon
3 important stitches to be comfortable with if you want to do minor surgery:
Simple interrupted
Vertical mattress
SubQ
Simple interrupted stitching may cause _______ scarring
railroad
Vertical mattress is (easy/hard) to evert under tension.
easy
better for cosmesis
Horizontal mattress is good for (high/low) tension wounds and (fragile/dense) tissue
high
fragile
Deep or buried stitches - use ______ suture.
absorbable
for large or deep wounds
What are some indications for using subcuticular/intradermal running stitches:
dermal layer
not visible
eliminates tracts
linear wounds with little tension
Running stitches are:
less secure
high risk of infection
quick to put in
not cosmetic
3-point, half-buried stitches are good for:
triangular flaps without strangulation
Two main classes of suture materials:
absorbable (natural, synthetic)
non-absorbable
Natural absorbable sutures are digested by:
body enzymes
Which natural absorbable suture is less reactive?
chromic catgut - chromic salt delays absorption, has 2-3 week 1/2 life
plain catgut > chromic catgut > synthetic sutures
_______ sutures are hydrolyzed and easy to tie.
synthetic
Characteristics of silk sutures:
high tissue reactivity
easy to tie
Characteristics of stainless steel:
minimal tissue reactivity
permanent
Characteristics of polyester/polybutester:
high tissue reactivity
Characteristics of nylon/ethilon:
low tissue reactivity, low risk of infx
slips easily
monofilament
Staples:
minimal tissue reactivity, low risk of infx
fast
uncomfortable
Use ____ knots per gauge:
one knot over gauge (5 knots for a 4-0)
Suturing face/neck - gauge, remove:
5-0, 6-0
3-5 days
Suturing arm/hand - gauge, remove:
4-0, 5-0
7-10 days
Suturing trunk/leg/foot/scalp - gauge, remove:
3-0, 4-0
7-14 days
Reverse cutting is (most/least) common
most common for procedures
Dress wounds for:
absorption of drainage
support
moisture for epithelialization
limits movement
Post-op, keep wounds dry for _____ hours.
24-48
Post-op, keep wounds dry for _____ hours.
24-48
Infections are common ____ days post-procedure, and the most common pathogen is ___________
4-10 days
staph aureus
Blood collection following surgery is called ______, happens _____ hours after surgery, and may lead to infection or ______.
hematoma
24-72 hours
dehiscence
Wound rupture along the incision after suture is closed is called ______. You can re-suture within ____. After that window, you want to:
dehiscence
48-72 hours
let it heal by secondary intention
Local antisthetics block ___ reuptake, to prevent:
sodium depolarization and propagation of pain stimuli
10cc of 1% lidocaine = __ mg
100mg lidocaine
IM injection angle:
90 degrees
SubQ injection angle:
30-45 degrees
Intradermal injection angle:
5-10 degrees
Amides are metabolized in the _____, and true allergies are (common/rare).
liver
rare
Lidocaine/xylocaine has a ___ min onset, ___ min duration.
1-10 mins to onset
30-60 min duration
Max dose of lidocaine in a child:
3.3-4.5 mg/kg, not to exceed 75-110mg
Max dose of lidocaine in an adult:
4.5 mg/kg, not to exceed 300mg (30cc of 1%)
Bupivacaine/marcaine has a ___ min onset, ___ hour duration. Indicated for:
8-12 min onset
3-4 hour duration
digital block
Max dose
4 mg/kg of 0.25%, not to exceed 200mg
Esters are metabolized in ________ by pseudocholinesterase
peripheral plasma
more reactions
3 ingredients in TAC:
Tetracaine (ester)
Epinephrine
Cocaine
3 ingredients in TAC:
Tetracaine (ester)
Epinephrine
Cocaine
We pull back on the plunger before injecting to avoid what adverse reaction?
Inadvertant intravascular injection
excessive dose
Too much anesthetic, give:
oxygen
CNS depressant may cause hypotension, then bradycardia or arrest
Treat mild allergic reactions with _____.
Treat severe allergic reactions with ______.
Benadryl (15 mins)
epinephrine and oxygen
mc with
esters
In true anaphylaxis reaction, how do pulse and BP change?
HR up / BP down
[vs. autonomic response - both go up]
Uses of epinephrine: (vasoconstriction)
- decrease oozing
- prolong duration by limiting absorption into tissues
- decreasing risk of toxic reactions by reducing circulating anesthetic
Side effects of epinephrine:
anxiety restlessness tremor palpitations tachycardia
Epinephrine dose for anesthetic use:
1:200,000
< 0.2 mg
Epinephrine dose for anaphylaxis:
1:1000
Antidote
IV push of magnesium and B6
COMT
Contraindications of epinephrine use:
End-arteries (fingers, nose, toes, penis, clitoris, ears)
MAOIs, TCAs, thyrotoxicosis, severe CAD
caution with PVD, HTN
3 parts of the sterile field:
- physician - gloves, washing, mask
- patient - sterile drape, incision area
- tray - tools, materials
Contraindications to ND PCP doing minor surgery
- location - lesion on nose, eye, axilla, groin, post neck
- large size / blood supply
- depth - lipomas can be intertwined in mm/bone
- young children
- pt on anti-coags / with bleeding disorder
- pt on a corticosteroid
- pulsating lesion
- keloid forming pt
- systemic illness with depleted immune system
Tissue destruction methods:
Never use if:
cryotherapy
electrosurgery
** if you want to biopsy! **
Cryotherapy - freezing with _______, which leads to anoxia and death.
“cryogen”
- HistoFreeze - aerosol
- Dry ice
- Nitrous oxide
- liquid nitrogen - MC
If you are going to freeze warts, start by:
using #10 scalpel blade to shave it down to black dots or pin-prick bleeding, THEN cryo
Cryotherapy is indicated for:
- warts
- skin tags (acrochordon)
- seb keratosis
- actinic keratosis
Dry ice isn’t used much anymore, because:
it’s simple, cheap, but not very effective
Transport liquid nitrogen in a:
Never use straight from bottle, risk of:
Dewar bottle
HPV transmission
Liquid nitrogen - freeze, thaw, refreeze, with ___mm zone around lesion.
May cause __________
2-3 mm
depigmentation
Types of electrosurgery:
- Electrocautery - indirect, precise
* Hyfrecation - direct
Describe proper excisional biopsy technique:
3:1 elliptical excision with 30 deg corners
#15 scalpel
parallel to Langer’s Lines
Punch biopsy technique:
traction perpendicular to Langer’s Lines
1-2mm beyond edge of lesion
full thickness of dermis
When do you use #10, 11, and 15 scalpels?
11 - puncture abscess, incision, stabbing
15 - blunt dissection, excision, trimming
10 - like 15, thick skin
When do you use non/toothed forceps?
Toothed adson - does not crush skin
Toothless - crushes skin, foreign body removal
When do you use iris vs metzenbaum scissors?
Iris - fine dissection, not for sutures
Metzenbaum - blunt dissection
